Reactions 1704, p300 - 2 Jun 2018 Focal immune-related pancreatitis: case report A 76-year-old woman developed focal immune-related pancreatitis following treatment with pembrolizumab. The woman, who had urothelial carcinoma and local nodal recurrence, started receiving treatment with IV pembrolizumab 200 mg/3 weeks. Her concurrent treatment included R0 nephroureterectomy, methotrexate, vinblastine, adriamycin and cisplatin. Subsequently, she developed grade 2 diarrhoea and weight loss. Further CT examination revealed mild dilation of the main pancreatic duct (MPD). Subsequent MRI and cholangiopancreatography confirmed MPD dilation secondary to a tapered stricture in the pancreatic head. On diffusion-weighted image, a marked increase in signal intensity of a region of the pancreatic head was observed, indicating restricted diffusion. A subsequent endoscopic ultrasound (EUS) revealed a 2cm hypoechoic solid lesion of the pancreatic neck, stiff at elastography, with low vascularity after the administration of contrast agent, causing stenosis of the MPD with upstream dilation. Therefore, pancreatic adenocarcinoma was suspected. However, fine-needle aspiration was found to be negative for neoplasia, but revealed a dense granulocytic inflammation. Subsequent laboratory investigation revealed decreased level of faecal elastase 41 mcg/g (normal>200) suggestive of exocrine pancreatic insufficiency. Therefore, the woman was treated with pancreatic enzyme replacement therapy. Subsequently, prompt diarrhoea resolution and weight gain was observed. Two months later, a follow-up EUS revealed disappearance of the lesions and only ﬁnding of hypoechoic and inhomogeneous parenchyma, diffuse hyperechoic foci and strands, with pancreatic head atrophy. The MPD was found to be thin and irregular. According to the Rosemont classification, these findings were consistent with chronic pancreatitis. Additionally, distal common bile duct and superior mesenteric artery demonstrated thickening of walls (1 and 1.6mm, respectively), as in cases of cholangitis and vasculitis. Two months later, an MRI scan using diffusion-weighted imaging revealed absence of any solid pancreatic lesion. She remained asymptomatic, although faecal elastase levels remained low. Her final diagnosis was focal immune-related pancreatitis considered to be secondary to pembrolizumab treatment [duration of treatment to reaction onset not stated]. Author comment: "We believe that clinicians using these drugs [pembrolizumab] should be aware that immune-related pancreatitis might present without amylase or lipase increase or overt symptoms of acute pancreatitis but possibly as a focal pancreatic lesion, and with diarrhoea and weight loss due to [exocrine pancreatic insufficiency], which might be appreciated by careful imaging procedures and measure of faecal elastase levels." Capurso G, et al. Focal immune-related pancreatitis occurring after treatment with programmed cell death 1 inhibitors: a distinct form of autoimmune pancreatitis? European Journal of Cancer 95: 123-126, May 2018. Available from: URL: http:// doi.org/10.1016/j.ejca.2018.02.006 - Italy 803323324 0114-9954/18/1704-0001/$14.95 Adis © 2018 Springer International Publishing AG. All rights reserved Reactions 2 Jun 2018 No. 1704
Reactions Weekly – Springer Journals
Published: Jun 2, 2018
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